HIGHER EDUCATION OFFICE OF HEALTH SERVICES 

LOYOLA SCHOOLS (LS-OHS) 

ONLINE WAIVER/CONSENT FORM

• I hereby consent to consult the LS OHS health services for medical assistance such as assessing / diagnosing /managing my medical condition, or addressing health education needs using a telecommunications program. I understand that the consultation may require communication of personal medical information.

• I confirm that medical professionals can reach me with video calls or audio calls as part of the online sessions.

• I acknowledge that in this type of platform technical difficulties may happen which might cause a slight delay or might need rescheduling.

• I accept that it is my responsibility to provide all necessary information, such as signs and symptoms, medical history, and current condition, to the health professional, and I undertake to ensure that the information I will provide during the online session is accurate and true.

•  I confirm that online health services require the collection of personal medical data by the health professional remotely. I understand that data transmitted and received through the online session is considered confidential for both parties, subject to Data Privacy laws.

• I understand that this online session does not and should not replace a traditional doctor’s office visit; and therefore, I am proceeding with this consultation at my own risk and understanding.

•  If the physician who will attend to me deems it necessary to have a face-to-face consultation, then I may be advised to consult my Family Doctor.

•  Finally, I understand that there are potential risks and benefits associated with any form of medical treatment, and despite the physician’s due diligence, my condition may not improve, or may even worsen. Therefore, I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured.

•  I have read and understand the information provided above.